I understand and acknowledge that my insurance company pays only for covered services as they are defined in my insurance policy. I also understand that my insurance company has informed Medina Vision Centre that, per contractual agreement, I (the insured) may not be eligible to receive services if one of the following situations applies:
1.) I am not an eligible member.
2.) The services requested were denied by my insurance company as not medically appropriate or
necessary.
3.) The requested service is not a covered service as defined in my insurance policy.
4.) I do not have prior authorization for requested service(s) from my insurance company. (Is a
referral needed?)
I also understand that I am financially responsible for all copayments, annual deductibles, and charges for any non-covered, elective service.